Skip to main content Accessibility help
×
Home
  • Print publication year: 2009
  • Online publication date: May 2010

18 - Infections in stroke

from Section IV - Therapeutic strategies and neurorehabilitation

Summary

Introduction

Bacterial, viral and parasitic infections are associated with stroke in several ways. First, at least 20% of strokes are preceded by a bacterial infection in the month prior to stroke. Second, many pathogens that affect the central nervous system are able to directly cause stroke. Third, patients who suffer a stroke are prone to develop infectious complications due to post-stroke immunodepression and impaired swallow and cough reflexes.

In this chapter, we will briefly summarize available evidence on how bacterial infections can trigger stroke. Then, specific infectious diseases are reviewed that are a direct cause of stroke, such as endocarditis, vasculitis and chronic meningitis. Furthermore, aspiration pneumonia is discussed, as an example of an early infectious complication that arises within the first week after stroke. Late infectious complications, occurring later than a week after stroke, such as ventilator-associated pneumonia or catheter-related infections, will not be covered since they are common infections in the hospital with no specific link to stroke.

Infections preceding stroke

Recent infection and stroke

Several studies have supplied evidence that acute infection in the week preceding stroke is an independent risk factor for cerebral infarction (odds ratio 3.4–14.5) [1–3]. Especially bacterial respiratory and urinary tract infections can trigger ischemic stroke [4]. Since a heterogeneous group of microbial pathogens is involved, the systemic inflammatory response is probably more important than microbial invasion per se. However, a detailed molecular understanding of events that lead to a higher susceptibility to cerebral infarction is lacking.

Related content

Powered by UNSILO
References
Grau, AJ, Buggle, F, Heindl, S, et al. Recent infection as a risk factor for cerebrovascular ischemia. Stroke 1995; 26:373–9.
Paganini-Hill, A, Lozano, E, Fischberg, G, et al. Infection and risk of ischemic stroke: differences among stroke subtypes. Stroke 2003; 34:452–7.
Smeeth, L, Thomas, SL, Hall, AJ, et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med 2004; 351:2611–8.
Lichy, C, Grau, AJ. Investigating the association between influenza vaccination and reduced stroke risk. Expert Rev Vaccines 2006; 5:535–40.
Watson, C, Alp, NJ. Role of Chlamydia pneumoniae in atherosclerosis. Clin Sci (Lond) 2008; 114:509–31.
Elkind, MS, Cole, JW. Do common infections cause stroke?Semin Neurol 2006; 26:88–99.
Grau, AJ, Marquardt, L, Lichy, C. The effect of infections and vaccinations on stroke risk. Expert Rev Neurother 2006; 6:175–83.
Grayston, JT, Kronmal, RA, Jackson, , et al. Azithromycin for the secondary prevention of coronary events. N Engl J Med 2005; 352:1637–45.
O'Connor, CM, Dunne, MW, Pfeffer, MA, et al. Azithromycin for the secondary prevention of coronary heart disease events: the WIZARD study: a randomized controlled trial. JAMA 2003; 290:1459–66.
Ngeh, J, Goodbourn, C. Chlamydia pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila in elderly patients with stroke (C-PEPS, M-PEPS, L-PEPS): a case-control study on the infectious burden of atypical respiratory pathogens in elderly patients with acute cerebrovascular disease. Stroke 2005; 36:259–65.
Bayer, AS. Infective endocarditis. Clin Infect Dis 1993; 17:313–20.
Snygg-Martin, U, Gustafsson, L, Rosengren, L, et al. Cerebrovascular complications in patients with left-sided infective endocarditis are common: a prospective study using magnetic resonance imaging and neurochemical brain damage markers. Clin Infect Dis 2008; 47:23–30.
Garrison, PK, Freedman, LR. Experimental endocarditis I. Staphylococcal endocarditis in rabbits resulting from placement of a polyethylene catheter in the right side of the heart. Yale J Biol Med 1970; 42:394–410.
Baddour, LM, Wilson, WR, Bayer, AS, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation 2005; 111:e394–434.
Horstkotte, D, Follath, F, Gutschik, E, et al. Guidelines on prevention, diagnosis and treatment of infective endocarditis executive summary; the task force on infective endocarditis of the European Society of Cardiology. Eur Heart J 2004; 25:267–76.
Carod-Artal, FJ. Chagas cardiomyopathy and ischemic stroke. Expert Rev Cardiovasc Ther 2006; 4:119–30.
Takeoka, M, Takahashi, T. Infectious and inflammatory disorders of the circulatory system and stroke in childhood. Curr Opin Neurol 2002; 15:159–64.
Chan, KH, Cheung, RT, Lee, R, et al. Cerebral infarcts complicating tuberculous meningitis. Cerebrovasc Dis 2005; 19:391–5.
Ecevit, IZ, Clancy, CJ, Schmalfuss, IM, et al. The poor prognosis of central nervous system cryptococcosis among nonimmunosuppressed patients: a call for better disease recognition and evaluation of adjuncts to antifungal therapy. Clin Infect Dis 2006; 42:1443–7.
Leite, AG, Vidal, JE, Bonasser Filho, F, et al. Cerebral infarction related to cryptococcal meningitis in an HIV-infected patient: case report and literature review. Braz J Infect Dis 2004; 8:175–9.
Williams, PL, Johnson, R, Pappagianis, D, et al. Vasculitic and encephalitic complications associated with Coccidioides immitis infection of the central nervous system in humans: report of 10 cases and review. Clin Infect Dis 1992; 14:673–82.
Flint, AC, Liberato, BB, Anziska, Y, et al. Meningovascular syphilis as a cause of basilar artery stenosis. Neurology 2005; 64:391–2.
Nakane, H, Okada, Y, Ibayashi, S, et al. Brain infarction caused by syphilitic aortic aneurysm. A case report. Angiology 1996; 47:911–7.
Scheid, R, Hund-Georgiadis, M, Cramon, DY. Intracerebral haemorrhage as a manifestation of Lyme neuroborreliosis?Eur J Neurol 2003; 10:99–101.
Nagel, MA, Cohrs, RJ, Mahalingam, R, et al. The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features. Neurology 2008; 70:853–60.
Reynolds, MA, Chaves, SS, Harpaz, R, et al. The impact of the varicella vaccination program on herpes zoster epidemiology in the United States: a review. J Infect Dis 2008; 197 Suppl 2:S224–7.
Tipping, B, Villiers, L, Wainwright, H, et al. Stroke in patients with human immunodeficiency virus infection. J Neurol Neurosurg Psychiatry 2007; 78:1320–4.
Connor, MD, Lammie, GA, Bell, JE, et al. Cerebral infarction in adult AIDS patients: observations from the Edinburgh HIV Autopsy Cohort. Stroke 2000; 31:2117–26.
Ortiz, G, Koch, S, Romano, JG, et al. Mechanisms of ischemic stroke in HIV-infected patients. Neurology 2007; 68:1257–61.
Salgado, AV, Furlan, AJ, Keys, TF. Mycotic aneurysm, subarachnoid hemorrhage, and indications for cerebral angiography in infective endocarditis. Stroke 1987; 18:1057–60.
Ho, CL, Deruytter, MJ. CNS aspergillosis with mycotic aneurysm, cerebral granuloma and infarction. Acta Neurochir (Wien) 2004; 146:851–6.
Huang, TE, Chou, SM. Occlusive hypertrophic arteritis as the cause of discrete necrosis in CNS toxoplasmosis in the acquired immunodeficiency syndrome. Hum Pathol 1988; 19:1210–4.
Idro, R, Jenkins, NE, Newton, CR. Pathogenesis, clinical features, and neurological outcome of cerebral malaria. Lancet Neurol 2005; 4:827–40.
Weimar, C, Roth, MP, Zillessen, G, et al. Complications following acute ischemic stroke. Eur Neurol 2002; 48:133–40.
Langhorne, P, Stott, DJ, Robertson, L, et al. Medical complications after stroke: a multicenter study. Stroke 2000; 31:1223–9.
Hilker, R, Poetter, C, Findeisen, N, et al. Nosocomial pneumonia after acute stroke: implications for neurological intensive care medicine. Stroke 2003; 34:975–81.
Martino, R, Foley, N, Bhogal, S, et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005; 36:2756–63.
Shigemitsu, H, Afshar, K. Aspiration pneumonias: under-diagnosed and under-treated. Curr Opin Pulm Med 2007; 13:192–8.
Perry, L, Love, CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001; 16:7–18.
Gleeson, K, Eggli, DF, Maxwell, SL. Quantitative aspiration during sleep in normal subjects. Chest 1997; 111:1266–72.
Prass, K, Braun, JS, Dirnagl, U, et al. Stroke propagates bacterial aspiration to pneumonia in a model of cerebral ischemia. Stroke 2006; 37:2607–12.
Prass, K, Meisel, C, Hoflich, C, et al. Stroke-induced immunodeficiency promotes spontaneous bacterial infections and is mediated by sympathetic activation reversal by poststroke T helper cell type 1-like immunostimulation. J Exp Med 2003; 198:725–36.
Dirnagl, U, Klehmet, J, Braun, JS, et al. Stroke-induced immunodepression: experimental evidence and clinical relevance. Stroke 2007; 38:770–3.
Trapl, M, Enderle, P, Nowotny, M, et al. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke 2007; 38:2948–52.
Meisel, C, Prass, K, Braun, J, et al. Preventive antibacterial treatment improves the general medical and neurological outcome in a mouse model of stroke. Stroke 2004; 35:2–6.
Chamorro, A, Horcajada, JP, Obach, V, et al. The Early Systemic Prophylaxis of Infection After Stroke study: a randomized clinical trial. Stroke 2005; 36:1495–500.
Harms, H, Prass, K, Meisel, C, et al. Preventive antibacterial therapy in acute ischemic stroke: a randomized controlled trial. PLoS ONE 2008; 3:e2158.
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med 2005; 171:388–416.
Naber, KG, Bergman, B, Bishop, MC, et al. EAU guidelines for the management of urinary and male genital tract infections. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU). Eur Urol 2001; 40:576–88.
Wisplinghoff, H, Seifert, H. Bloodstream infection and endocarditis. In Borriello, SP, Murray, PR, Funke, G, eds. Bacteriology. London: Hodder Arnold; 2005: 509–54.
Durack, DT, Lukes, AS, Bright, DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994; 96:200–9.
Li, JS, Sexton, DJ, Mick, N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30:633–8.
Cavassini, M, Meuli, R, Francioli, P. Complications of infective endocarditis. In Scheld, WM, Whitley, RJ, Marra, CM, eds. Infections of the central nervous system, 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2004: 537–68.